Ultrasound and Other Innovations for Fluid Management in the ICU.

Ultrasound is a user-dependent tool that can help guide therapy. The use of ultrasound to guide central line placement decreases complication rates. Cardiac ultrasound can help with the diagnosis of cases of hypotension. Lung and pleura ultrasound is a useful adjunct for diagnosis causes of desaturation. Abdominal ultrasound can help in rapid visitation of fluid and intra-abdominal structures.

Forty-eight hour kidney transplant admissions.

Forty-eight hour kidney transplantation admissions are a feasible option in selected recipients of live-donor allografts through the use of standardized post-operative protocols, multidisciplinary team patient care, and intensive follow-up at outpatient centers. Age, gender, and pre-transplant dialysis status did not impact the ability to achieve 48-hour admissions. We did not identify any other pre-operative risk factors that contributed to increased length of stay. Although ABO and highly sensitized recipients had longer lengths of stay, the subgroup was too small to achieve statistical significance. We did not encounter any readmissions within the first seven post-operative days. Further improvements in clinical management will enhance the potential to shorten the length of hospital stay for all kidney transplant recipients.

Significance of elevated transplant renal artery velocities in the postoperative renal transplant patient.

INTRODUCTION: Non-invasive imaging studies can provide visualization of allograft perfusion in the postoperative evaluation of newly transplanted renal allografts. AIM: The purpose of our study was to evaluate the significance of elevated renal artery velocities in the immediate postoperative period. METHODS: Peak systolic velocities (PSVs) were obtained in the transplanted renal artery of 128 patients immediately after transplantation. Repeat allograft Doppler ultrasonography was performed on patients with elevated values. RESULTS: Of the 128 patients, 57 (44.5%) had severely elevated Doppler velocities >400 cm/s on the initial studies. Three patients within this category had persistently elevated values of >400 cm/s, warranting angiographic visualization of the renal vessels. Stent placement within the transplanted renal artery was required in two of these patients. There was normalization of the PSV in the remaining patients. CONCLUSIONS: Routine allograft Doppler ultrasonography in the immediate postoperative period allows for visualization of allograft perfusion. Elevated renal artery velocities in the immediate postoperative period do not necessarily represent stenosis requiring intervention. Failure of the PSV to normalize may require further intervention, and angiography continues to be the gold standard.

Removal of foley catheters in live donor kidney transplant recipients on postoperative day 1 does not increase the incidence of urine leaks.

Catheterization of the urinary bladder during kidney transplantation is essential. The optimal time to remove the Foley catheter postoperatively is not universally defined. It is our practice to remove the Foley catheter on postoperative day 1 in live donor kidney transplant recipients who meet our standardized protocol criteria. We believe that early removal of Foley catheters increases patient comfort and mobility, decreases the risk of catheter associated urinary tract infections, and allows for decreased hospital length of stay. The hypothetical risk of early removal of Foley catheters would be the increased risk of urine leak. We reviewed 120 consecutive live donor kidney transplant recipients and found that there was not an increased incidence of urine leaks in patients whose Foley catheters were removed on postoperative day 1.

Shortened length of stay improves financial outcomes in living donor kidney transplantation.

Kidney transplantation is the preferred clinical and most cost-effective option for end-stage renal disease. Significant advances have taken place in the care of the transplant patients with improvements in clinical outcomes. The optimization of the costs of transplantation has been a constant goal as well. We present herein the impact in financial outcomes of a shortened length of stay after kidney transplant.

Impact of an inpatient palliative care team: a randomized control trial.

BACKGROUND: Palliative care improves care and reduces costs for hospitalized patients with life-limiting illnesses. There have been no multicenter randomized trials examining impact on patient satisfaction, clinical outcomes, and subsequent health care costs. OBJECTIVE: Measure the impact of an interdisciplinary palliative care service (IPCS) on patient satisfaction, clinical outcomes, and cost of care for 6 months posthospital discharge. METHODS: Multicenter, randomized, controlled trial. IPCS provided consultative, interdisciplinary, palliative care to intervention patients. Controls received usual hospital care (UC). SETTING AND SAMPLE: Five hundred seventeen patients with life-limiting illnesses from a hospital in Denver, Portland, and San Francisco enrolled June 2002 to December 2003. MEASURES: Modified City of Hope Patient Questionnaire, total health care costs, hospice utilization, and survival. RESULTS: IPCS reported higher scores for the Care Experience scale (IPCS: 6.9 versus UC: 6.6, p = 0.04) and for the Doctors, Nurses/Other Care Providers Communication scale (IPCS: 8.3 versus UC: 7.5, p = 0.0004). IPCS patients had fewer intensive care admissions (ICU) on hospital readmission (12 versus 21, p = 0.04), and lower 6-month net cost savings of $4,855 per patient (p = 0.001). IPCS had longer median hospice stays (24 days versus 12 days, p = 0.04). There were no differences in survival or symptom control. CONCLUSIONS: IPCS patients reported greater satisfaction with their care experience and providers' communication, had fewer ICU admissions on readmission, and lower total health care costs following hospital discharge.

Rotational Atherectomy in Octogenarians: Results and Follow Up.

We examined our first 390 rotational atherectomy procedures to determine success and complications rates of patients aged 80 or greater (Group I, N equals 35) as compared to those younger (Group II, N equals 355). Procedural success was achieved in 32/35 (91%) of Group I and 42/355 (96%) of Group II patients (p equals NS). Coronary artery bypass graft surgery was required in 2/35 (5.7%) of Group I and 7/355 (2%) of Group II patients. No deaths, Q wave infarctions, or perforations occurred in the elderly patients and only one of each was observed in the younger group. During clinical follow up (26 months, 3-50), 4/25 patients (16%) in the octogenarian group died. Two of the deaths were cardiac (including the only crossover to surgery). One patient who sustained a late non Q myocardial infarction was asymptomatic. Of the remaining 20 patients the anginal class was 0-II in 19 and III in one. Rotational atherectomy can achieve excellent short and long term outcomes in selected octogenarians. (c)2000 by CVRR, Inc.